Nasreen Mahomed

A gardener who coughed up blood

In April, 2006, a 32-year-old man was referred to us by his local primary health-care clinic, with a cough that had been present for 2 weeks, accompanied by mild haemoptysis and diff use pleuritic chest pain. He was from Mozambique, but had been working in Johannesburg—initially as a labourer on building sites, and then as a gardener. He did not smoke. He had been diagnosed as HIV positive in 2005. On examination, the patient was not underweight or short of breath. He had cervical, axillary, and inguinal lymphadenopathy. We heard coarse crackles over both lungs, and palpated the liver edge 8 cm below the costal margin. We found no splenomegaly or ascites. Chest radiography (fi gure) showed many round opacities. Ultrasonography of the abdomen showed many hypoechogenic lesions in the liver. Blood tests showed that the patient was mildly anaemic, with a normal white-cell count. However, the CD4 cell count was only 27 per μL. Serum concentrations of alkaline phos phatase and γ-gluta myltransferase were raised, at 335 U/L and 228 U/L respectively. Serological testing gave a positive result for hepatitis C. CT of the chest and abdomen showed many cystic lesions in the lungs and in the liver; an indirect haemagglutination assay was positive for Echinococcus spp, at a titre of 1:512; a titre of 1:20 is regarded as diagnostic. We prescribed albendazole, at a dose of 400 mg twice daily, and prednisolone. The patient was discharged after 2 weeks, and completed the course of albendazole, which consisted of three 4-week periods of medication, separated by 1-week intervals intended to reduce the risk of liver damage. In August 2006, repeat CT of the chest and abdomen revealed that the cysts had decreased in size and number. We did not start treatment with highly active antiretroviral drugs while the patient was taking albendazole, because of the possible drug interaction, the risk of iatrogenic liver damage, and the risk of immune reconstitution syndrome. The patient was counselled about the risks and management of HIV; we intended to prescribe antiretroviral drugs after he completed the course of albendazole. However, the patient did not attend follow-up appointments, and attempts to trace him were unsuccessful. Echinococcus is a tapeworm carried by dogs. As a gardener, our patient was at increased risk of unwittingly swallowing the tapeworm’s eggs, by which means people become infected; the peak age of infection is 30–40 years. After being swallowed, the eggs release embryos, which travel in the bloodstream before lodging in organs such as the liver and lungs, where the embryos develop into cysts containing larvae. Echinococcus cysts are also known as hydatid cysts. Most cysts are asymptomatic; indeed, they are often found serendipitously, on radiological testing. Patients with AIDS are more likely to have echinococcal disease that develops rapidly and manifests early. However, our patient presented with mild symptoms, despite disseminated cystic disease and infection with hepatitis C. We speculate that perhaps the mildness of the symptoms was caused by the impairment of his immune response. Although our patient accepted treatment for tapeworm infestation and HIV counselling, he did not attend appointments for HIV treatment. He may have feared unemployment; his health beliefs may have caused him to doubt the diagnosis or treatment of AIDS; the grief or stigma of the diagnosis may have prevented him from accepting it.

Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome in children.

Paradoxical tuberculosis (TB)‐associated Immune Reconstitution Inflammatory Syndrome (IRIS) is a common complication of combination antiretroviral treatment (cART) initiation in adults residing in resource‐limited regions. Little is known about the burden and presentation of TB‐IRIS in children initiating cART while receiving TB treatment.

Corpus callosum thickness in children: an MR pattern-recognition approach on the midsagittal image.

Thickening of the corpus callosum is an important feature of development, whereas thinning of the corpus callosum can be the result of a number of diseases that affect development or cause destruction of the corpus callosum. Corpus callosum thickness reflects the volume of the hemispheres and responds to changes through direct effects or through Wallerian degeneration. It is therefore not only important to evaluate the morphology of the corpus callosum for congenital anomalies but also to evaluate the thickness of specific components or the whole corpus callosum in association with other findings. The goal of this pictorial review is raise awareness that the thickness of the corpus callosum can be a useful feature of pathology in pediatric central nervous system disease and must be considered in the context of the stage of development of a child. Thinning of the corpus callosum can be primary or secondary, and generalized or focal. Primary thinning is caused by abnormal or failed myelination related to the hypomyelinating leukoencephalopathies, metabolic disorders affecting white matter, and microcephaly. Secondary thinning of the corpus callosum can be caused by diffuse injury such as hypoxic–ischemic encephalopathy, human immunodeficiency virus (HIV) encephalopathy, hydrocephalus, dysmyelinating conditions and demyelinating conditions. Focal disturbance of formation or focal injury also causes localized thinning, e.g., callosal dysgenesis, metabolic disorders with localized effects, hypoglycemia, white matter injury of prematurity, HIV-related atrophy, infarction and vasculitis, trauma and toxins. The corpus callosum might be too thick because of a primary disorder in which the corpus callosum finding is essential to diagnosis; abnormal thickening can also be secondary to inflammation, infection and trauma.

Imaging of thoracic tuberculosis in children: current and future directions

Tuberculosis continues to be an important cause of morbidity and mortality worldwide. It is the leading cause of infection-related deaths worldwide. Children are amongst the high-risk groups for developing tuberculosis and often pose a challenge to the clinicians in making a definitive diagnosis. The newly released global tuberculosis report from World Health Organization reveals a 50% increase in fatality from tuberculosis in children. Significantly, diagnostic and treatment algorithms of tuberculosis for children differ from those of adults. Bacteriologic confirmation of the disease is often difficult in children; hence radiologists have an important role to play in early diagnosis of this disease. Despite advancing technology, the key diagnostic imaging modalities for primary care and emergency services, especially in rural and low-resource areas, are chest radiography and ultrasonography. In this article, we discuss various diagnostic imaging modalities used in diagnosis and treatment of tuberculosis and their indications. We highlight the use of US as point-of-care service along with mediastinal US and rapid MRI protocols, especially in mediastinal lymphadenopathy and thoracic complications. MRI is the ideal modality in high-resource areas when adequate infrastructure is available. Because the prevalence of tuberculosis is highest in lower-resource countries, we also discuss global initiatives in low-resource settings.

Preliminary report from the World Health Organisation Chest Radiography in Epidemiological Studies project.

Childhood pneumonia is among the leading infectious causes of mortality in children younger than 5 years of age globally. Streptococcus pneumoniae (pneumococcus) is the leading infectious cause of childhood bacterial pneumonia. The diagnosis of childhood pneumonia remains a critical epidemiological task for monitoring vaccine and treatment program effectiveness. The chest radiograph remains the most readily available and common imaging modality to assess childhood pneumonia. In 1997, the World Health Organization Radiology Working Group was established to provide a consensus method for the standardized definition for the interpretation of pediatric frontal chest radiographs, for use in bacterial vaccine efficacy trials in children. The definition was not designed for use in individual patient clinical management because of its emphasis on specificity at the expense of sensitivity. These definitions and endpoint conclusions were published in 2001 and an analysis of observer variation for these conclusions using a reference library of chest radiographs was published in 2005. In response to the technical needs identified through subsequent meetings, the World Health Organization Chest Radiography in Epidemiological Studies (CRES) project was initiated and is designed to be a continuation of the World Health Organization Radiology Working Group. The aims of the World Health Organization CRES project are to clarify the definitions used in the World Health Organization defined standardized interpretation of pediatric chest radiographs in bacterial vaccine impact and pneumonia epidemiological studies, reinforce the focus on reproducible chest radiograph readings, provide training and support with World Health Organization defined standardized interpretation of chest radiographs and develop guidelines and tools for investigators and site staff to assist in obtaining high-quality chest radiographs.

Recurrent Urinary Tract Infections in a Female Child With Polydactyly and a Pelvic Mass: Consider the McKusick-Kaufman Syndrome

A 3-year-old female child presented with a history of recurrent urinary tract infections. On general examination, polydactyly and a pelvic mass were present. An imperforate hymen was also documented on vaginal inspection. Further inquiry revealed a positive history of parental consanguinity. A magnetic resonance imaging study defined a hydrometrocolpos responsible for an obstructive cause of the recurrent urinary tract infections. In view of the above, a diagnosis of McKusick-Kaufman syndrome was made. Formal surgical repair of the imperforate hymen with hydrometrocolpos drainage resulted in complete symptom resolution. McKusick-Kaufman syndrome, its presentation, symptoms, differential diagnosis, and underlying genetics were further expanded.

A systemic review of tuberculosis with HIV coinfection in children

The epidemiology of tuberculosis is adversely impacted by the human immunodeficiency virus (HIV) coinfection. HIV-infected patients are more prone to opportunistic infections, most commonly tuberculosis, and the risk of death in coinfected patients is higher than in those without HIV. Due to the impaired cellular immunity and reduced immunological response in HIV-infected patients, the classic imaging features of tuberculosis usually seen in patients without HIV may present differently. The aim of this review article is to highlight the imaging features that may assist in the diagnosis of tuberculosis in patients with HIV coinfection.

Radiologic diagnosis of chest infection in children: WHO end-point consolidation

Pneumonia caused by Streptococcus pneumoniae is the leading cause of morbidity and mortality in children younger than 5 years, with pneumococcal conjugate vaccines providing an opportunity to reduce this burden of illness [1]. In 2007 the World Health Organization (WHO) recommended global expansion of the 7-valent pneumococcal conjugate vaccine (PCV-7), with priority introduction in countries with a <5years-old child mortality rate of >50/1,000 live births, in countries where >50,000 children die annually and in countries with a high prevalence of human immunodeficiency virus (HIV) [2]. Because radiologic diagnosis of pneumonia is used as the outcomemeasure in epidemiological trials, a standardizedmethod for radiographically diagnosing pneumonia was developed by the WHO radiologic working group (initially established in 1997) to provide a consensus method for reading chest radiographs in vaccine efficacy and epidemiological trials of pneumonia [3]. End-point consolidation was defined as a dense or fluffy opacity that occupied a portion, a lobe or an entire lung, with or without air bronchograms. Primary end-point pneumonia was defined as end-point consolidation or pleural effusion involving the lateral pleural space and associated with pulmonary parenchymal infiltrate, or an effusion that “obliterated enough of the hemithorax to obscure an opacity” [3]. The 9-valent pneumococcal conjugate vaccine reduced the incidence of WHO defined chest-radiograph-confirmed pneumonia by 25% in non-HIV-infected South African children [4] and by 37% in Gambian children [5]. The pneumococcal conjugate vaccine (PCV) also reduced the incidence of vaccine serotype and antibiotic-resistant invasive pneumococcal disease among HIV-infected and non-HIV-infected South African children [6]. A post hoc analysis of the South African PCV trial, however, suggested WHO radiologic end point under-estimated the burden of pneumonia prevented by vaccination [6]. This could be attributed to the pre-determined chest radiograph end point being geared toward improved specificity, rather than sensitivity [3]. In the United States, where the introduction of childhood pneumococcal conjugate vaccine immunization has resulted in a 36% reduction in allcause pneumonia, many children included were unlikely to have fulfilled the WHO predetermined end point of “radiologically confirmed” pneumonia [7]. The current aim of the WHO is to re-establish a radiology working group with the objective of providing a more sensitive end point for radiologically confirmed pneumonia, without compromising on specificity, with which to measure vaccine effectiveness in preventing pneumonia. This would be important in future international studies evaluating the full public health benefit of immunization with pneumococcal conjugate vaccines and pneumonia epidemiological studies.

The ectopic posterior pituitary gland

An ectopic posterior pituitary gland is a rare condition and may present with an empty pituitary fossa, hypoplasia or absence of the infundibular stalk and resultant short stature due to growth hormone deficiency. The location of the ectopic lobe can vary, but it is most commonly situated along the median eminence in the floor of the third ventricle. We report a case of an ectopic posterior pituitary gland, describe the causes and discuss the diagnostic imaging features.

Immune Reconstitution Inflammatory Syndrome in children

Immune Reconstitution Inflammatory Syndrome (IRIS) refers to a collection of inflammatory disorders, predominantly related to infectious processes that manifest after the initiation of antiretroviral therapy (ART) and can be classified as unmasking or paradoxical. The prevalence of IRIS in children in sub-Saharan Africa is low. Approximately half of all cases are associated with Mycobacterium tuberculosis. It may be difficult to distinguish IRIS from tuberculosis and other opportunistic infections radiologically; therefore, radiological findings must be interpreted with clinical and laboratory findings. In this review article, we describe the clinical and radiological manifestations of IRIS in children and provide illustrative radiological examples.